Inspection of the respiratory system (lungs)

The doctor receives certain objective information already when talking to the patient and  general examination : the general appearance of the patient, the position (active, passive, forced on the diseased side with pleurisy and pleuropneumonia), the condition of the skin and visible mucous membranes (cyanosis, pallor, the presence of herpetic rashes on lips, wings of the nose and one-sided hyperemia of the face as signs accompanying pneumonia). Particular attention is paid to changing the  shape of the nails  according to the type of watch glass and the  end phalanges of fingers  like the drumsticks (Hippocrates fingers), characteristic of chronic pulmonary suppuration (bronchiectasis, lung abscess), and bronchogenic cancer, fibrosing alveolitis.

This sign (especially with reference to bronchogenic carcinoma) is also called pulmonary hypertrophic osteoarthropathy (meaning the possibility of hitting other bones with pain in them). It should be remembered, however, that this symptom can also be associated with non-pulmonary diseases ("blue" congenital heart defects, subacute  infective endocarditis,  liver cirrhosis,  ulcerative colitis, aneurysm of the subclavian artery, chronic hypoxia in high altitude conditions). There can be family cases of such changes.

In some diseases of the lung, eye lesions are found  :  nonspecific  keratoconjunctivitis  in primary tuberculosis,  iridocyclitis  also in tuberculosis and sarcoidosis.

Examination of the  lymph nodes  is important: an increase in supraclavicular lymph nodes can occur with lung tumors (metastasis),  lymphoma,  sarcoidosis, tuberculosis and requires a biopsy.

Some skin  changes  can lead to suspicion or help to understand the development of the pulmonary process. Thus,  erythema nodosum  is a very characteristic nonspecific sign of sarcoidosis (as well as peculiar specific sarcoid nodules); with  bronchogenic cancer  , metastatic nodules can be detected in the skin; damage to the lungs in systemic diseases is accompanied by the appearance on the skin of various eruptions ( hemorrhagic vasculitis  , etc.).

Diseases associated with the syndrome "fingers of Hippocrates"

Diseases of the respiratory system:

1. Bronchogenic cancer.
2. Chronic suppuration ( bronchoectatic disease, abscess,  empyema ).
3. Fibrozing alveolitis.
4. Asbestosis.

Diseases of the cardiovascular system:

1. Congenital heart defects (blue type).
2. Subacute infective endocarditis.
3. Aneurysm of the subclavian artery.

Diseases of the gastrointestinal tract:

1. Cirrhosis of the liver.
2. Nonspecific ulcerative colitis.
3. Syndrome of impaired suction (steatorrhea).
4. Family (congenital) changes in phalanges. Hypoxia of the highlands.

At the general or common survey reveal such important signs, as a cyanosis and edemas.

Cyanosis  (cyanosis) - a peculiar change in the color of the skin is usually best found on the lips, tongue, ear shells, nails, although it sometimes has a total character. Pulmonary  cyanosis  often occurs with alveolar hypoventilation or a violation of the balance between ventilation and perfusion. The severity of cyanosis depends on the content of reconstituted hemoglobin in the tissue capillaries, so patients with anemia, even at low PO2, do not look cyanotic, and vice versa, with polycythemia cyanosis is usually easy to detect, although the blood oxygen tension is normal or even increased. Local cyanosis of the extremities can be associated with shunting of a large part of the blood that does not reach the extremities (shock).

For lung diseases (primarily obstructive), as well as  pneumonia,  bronchial asthma, fibrosing alveolitis, the so-called central cyanosis, which develops in connection with peripheral vasodilation and the accumulation of carbon dioxide in the blood, is characteristic. Peripheral cyanosis  with a predominant color change in the face, neck, and sometimes the upper limbs is more often due to compression of the superior vena cava. Such compression (for example, with  lung cancer ) is accompanied by local edema and the development of venous collaterals on the front surface of the chest.

Usually,  edematous syndrome  in a patient with lung disease is a sign of right ventricular heart failure.

The study of the respiratory system  begins with the question of nasal breathing, the presence of  nasal bleeding. In passing, the voice, its changes, in particular hoarseness, are evaluated  .

The doctor receives important data on examination and  palpation of the chest,  percussion  and  auscultation of the lungs.

Chest examination is performed with normal breathing and in conditions of its amplification. The depth and frequency of respiration are  determined  (normally the number of respiratory movements and heart rate are 1: 4), the degree of involvement, the ratio of inspiratory and exhalation times (exhalation prolongation with obstruction of small bronchi, difficulty in inhaling until wheezing, noisy, so-called stridorous respiration narrowing of the trachea and major bronchi), the symmetry and character of the respiratory movements of the chest.

It should be remembered that breathing constantly changes the intrathoracic pressure, so that air enters and exits from the pulmonary alveoli along the respiratory tract. When you inhale, the diaphragm descends, the chest moves up and to the sides, which increases the intrathoracic volume, reduces the intrathoracic pressure, and air enters the alveoli. Under normal conditions, that the necessary amount of oxygen and removal of carbon dioxide is provided in the respiratory minute volume  5 -6 liters of air.

Increase in minute ventilation is primarily achieved by frequent breathing (tachypnea), but without increasing its depth, which, for example, occurs with advanced pulmonary fibrosis, pleural diseases, chest stiffness, pulmonary edema. Breathing increases (tachypnea) and becomes deeper (hyperpnoea) - the so-called "air hunger", or Kussmaul's breathing, for example, with  diabetic ketoacidosis, renal  metabolic acidosis. Minute ventilation varies with diseases of the central nervous system: with meningitis it increases, with tumors and hemorrhage due to  increased intracranial pressure  decreases. Inhibition of ventilation is observed under the influence of anesthetics and other drugs.

When examined, you can find a forced exhalation - the effort necessary to increase the intrathoracic pressure to overcome the resistance to free air flow to the outside, which is typical for chronic obstructive pulmonary diseases ( chronic bronchitis, emphysema, bronchial asthma). In addition to elongation of exhalation, the inclusion of auxiliary muscles of the neck, shoulder girdle, intercostal spaces is revealed.

The  shape of the chest,  its mobility during breathing (participation in the act of breathing) are evaluated. Distinguish normostenicheskuyu, asthenic and hypersthenic thoracic cells, which corresponds to other signs of a certain constitutional type of man. Thus, due to the proportional ratio of antero-posterior and transverse dimensions with normosthenic form  , the epigastinal angle  formed by the rib arches is equal to 90 °, the ribs are oblique, the supra- and subclavian fossae are moderately expressed, the scapulas are closely adjacent to the back. In contrast, with asthenic form, the thorax is flat, the epigastral angle is less than 90 °, the ribs are more vertical, the scapulae have the appearance of wings, and when hypersthenic, these orientations have the opposite direction.

Depending on the lesions of the lungs and the pleura or changes in the bone skeleton, these types of chest can acquire peculiar pathological forms. Paralytic (more pronounced signs of asthenic type) occurs when chronic chronic wrinkling (sclerosing) processes in the lungs or pleura that began usually in childhood; barrel-shaped, emphysematous (strongly pronounced signs of hypersthenic type) develops due to the widespread hyper-airflow (emphysema) of the lungs caused by loss of elasticity of the lung tissue and the inability to recede the lungs during exhalation, which is accompanied by a reduction in the respiratory excursion characteristic of the emphysematous thorax. Incorrect formation of the skeleton in rickets in childhood leads to a so-called rachitic thorax with a protruding breastbone ("chicken breast"). In connection with changes in the osseous system, a funnel-shaped chest is distinguished   (sternal inward insertion - "cobbler's chest") and scaphoid (widespread boat-shaped depression of the upper part of the thoracic wall in front). Of particular importance are the changes in the shape of the chest in connection with the scars of the thoracic spine:  lordosis  (convexity of the spine forward),  kyphosis  (convexity of the spine posteriorly),  scoliosis  (bending of the spine to the side), but especially kyphoscoliosis, when in unusual conditions the heart and large vessels, including the vessels of the lungs, which leads to the gradual development of right ventricular heart failure ("kyphoscoliotic heart").

Examination, especially dynamic, using deep breathing, allows to reveal asymmetry of the chest: asymmetry of the form (bulging, retraction) and asymmetry of participation in the act of breathing. The bulging of the corresponding half of the chest wall with the smoothness of the intercostal spaces usually develops in the presence of fluid ( pleurisy, hydrothorax) or gas ( pneumothorax ) in the pleural cavity, sometimes with a common infiltrate (pneumonia) or a large lung tumor. The retraction of one half of the thorax is observed with the widespread wrinkling of the lung fibrous process and the development of obturation  atelectasis  (collapse) of the lobe of the lung due to occlusion of the draining of this proportion of the bronchus (endobronchial puhol, compression from the outside, foreign body in the bronchus lumen). Usually in all these cases, half of the chest corresponding to deformation lags behind in breathing or does not participate in the act of breathing at all, and thus the detection of this phenomenon is of great diagnostic importance.

[1], [2], [3]